Basic Information
| Provider Information | |||||||||
| NPI: | 1215987235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASH | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2331 PROGRESS ST | ||||||||
| Address2: | |||||||||
| City: | WEST BRANCH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486619384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893451184 | ||||||||
| FaxNumber: | 9893456944 | ||||||||
| Practice Location | |||||||||
| Address1: | 2331 PROGRESS ST | ||||||||
| Address2: | |||||||||
| City: | WEST BRANCH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486619384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893451184 | ||||||||
| FaxNumber: | 9893456944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 01/27/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101009465 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 700G210140 | 01 | MI | BCBS | OTHER | 4737473 | 05 | MI | MEDICAID | 4737464 | 05 | MI | MEDICAID | 08OG21014 | 01 | MI | BCBS | OTHER | 4737553 | 05 | MI | MEDICAID | P00258725 | 01 | MI | RAILROAD MEDICARE | OTHER | 4737455 | 05 | MI | MEDICAID |